Iris Doria Rhoda Vergara

Team Communication

Coordinating Care
Discharge Planning Family Meeting Universal Protocol

Good communication is about breaking down barriers to effective interaction.

A communication barrier is anything that blocks, degrades or interferes with clear exchange of ideas. Cultural barriers: Shyness; excessive deference to authority; keeping quiet to avoid embarrassment. Rank, age, position barriers: Gaps between superiors and subordinates, between doctors and non-doctors

In the procedure room, doctors and nurses who may not know each other must quickly form teams that will perform high risk operations. Here are some techniques for rapidly initiating two-way communication and building rapport among crew members.

Introduce yourself
Easier to communicate with one you already know.

Walk your talk

Open stance, friendly voice allows others to open up to you

Make eye contact

Increases your chance of being understood.

Provide Big Picture

Before a procedure, review roles and critical points

Clearly tell team members to provide information, express their concerns and speak up when necessary. Say If you see anything that appears to be unsafe or otherwise causes your concern, please bring it to my attention immediately.

Ask Whats our patients status? to invite response Break the ice and begin cycle of communication Avoid hard questions. The aim is to invite participation, not test knowledge.

Insist on feedback.
MD to nurse: If I dont acknowledge your

question or comment, assume I didnt hear it and ask again. Nurse to MD: If I do not repeat your orders, assume I did not understand it and ask for a read back.

SEE IT!
SAY IT! FIX IT!

Be alert to anything that feels or appears wrong.

SPEAK UP regardless of authority or seniority.

Stop what you are doing and help your entire team reclaim collective situational awareness.

It is a communication tool to improve situational awareness It helps you to:

Precisely state your observations
Make clear and concise questions Accurately state your concerns

Specify the feedback you need

Suggest solutions

Keep an open mind

Be persistent in communicating your concerns

Be prompt in seeking help

Listen carefully to what is being communicated to you

 State the current situation, including Your name and unit Patients name, physician and room

number Brief statement of your concerns Patients immediate problems that you want addressed Reason for the call or referral

Provide a brief and pertinent history of the patient or situation, which may include:
Admission diagnosis

Recent interventions Abnormal lab or

and date of admission Pertinent medical history Brief summary of treatment to date Results of clinical assessments

imaging results Status of IV fluid Gait / fall precautions Diet Living situation / discharge plan Vaccines, allergies

 State what your understanding of

the problem, which may include

Your clinical impression or diagnosis
Your best calculated guess about the

patients problem or concern In other words, what do you think the problem is?

Give a suggested response based on the situation, background and assessment. In other words, what do you think needs to be done? The recommendation should include

Anything that needs to be attended immediately. Details on what the patients physician has been

told. Anything that has been left undone. Information on anything that could not be finished during your shift / time with the patient.

Use critical language to ensure that your recommendations are taken seriously Critical words convey urgency

Now

Must

Need

Immediately

Critical

Priority

Important

Quickly

Requires

At once

Instantly

Acute

Fast

Urgent

Essential

The receiving unit must be accurately endorsed to.

The information to be endorsed must include:

History and PE findings

Clinical impression and differential diagnosis STAT laboratory test results Interventions given at the endorsing unit The medical and nursing care plans

The Patient Passport is used to safely and efficiently endorse critical patient information during handoffs which includes patients condition, procedures, and other special endorsements.

Transfers from one hospital unit to another are guided by admission and discharge criteria specific to the sending and receiving units. MD to MD, and nurse to nurse endorsements occur at the time of transfer. The SBAR format is used in endorsing transferred patients.

Preoperative verification

Marking the procedure site

Sign in (pre-briefing) Time out

Sign out (de-briefing)

Consent has been obtained? Site has been correctly marked (if applicable) Patient has known drug allergies?

Patients identity, procedure and site confirmed? Prophylactic antibiotic given?

Difficult intubation prepared for?

Significant blood loss prepared for? Correct implants or special devices, if needed, are available

All diagnostic results are available MD briefed team on key procedure steps, potential problems and actions

Before performing the procedure, MD verbally declares

Patients name, planned procedure and site

Type of anesthesia and position of patient

They must agree on the Time Out details

The surgeon or radiologist

The patients anesthesiologist

The circulating nurse or radiologic technologist

Prior to removal of surgical drapes, surgeon reviews with team

Key intra-operative events and post-operative

care plan

Anesthesiologist reviews with team

Key intra-operative events and post-operative

recovery plan

Nurse reviews with team

Sponge and instrument counts Specimen labeling

It is a venue for patients and their family members to participate in the planning of health care goals.

A safe environment where questions can be raised by the family and appropriate strategies agreed upon Explain what the service can and cannot offer
Prioritize issues Referrals to other health professionals

Not an opportunity to debate a patients medical status

Prior planning for the meeting is imperative

Listening and Communicating

Facilitating Meetings

Disclosure

Diffusing Tension

Coaching

Goal Setting

It needs preparation
Inform attendees (family

Gather data about the family

Background Concerns Current action

carers, financiers, health care professionals) Set a time and place Establish the agenda beforehand

Documentation
Who were present

The decisions made

Contact details

Our responsibility towards our patients does not end upon their discharge

We have the duty to ensure that their care is seamlessly continued at home and in other places. Because our patients need to get out of their sick roles. Our patients need to re-imagine themselves as whole, self-sufficient and satisfied people again. They need wellness goals to aim for, mental images to sustain their recovery efforts.

Efficiently and safely separate the patient from the hospital setting

Coordinate continuing care in the community to ensure rehabilitation and/or recovery

Providing evidencebased INFORMATION to your patients

Titrate the amount and content of information against your patients educational readiness and ability.

Ensuring your patients UNDERSTANDING

Reaffirming your THERAPEUTIC ALLIANCE with your patient.

Constantly validate your patients / familys abilities to care for themselves and your continuing readiness to support their efforts.

Challenge your patient to paraphrase and demonstrate mastery of your educational messages.

Avoid getting sick again Take their medications and when Modify their diet if needed Resume normal activities and when Call for medical help if needed and whom Go for a follow-up visit and when

Their condition, treatments and outlook Diet and nutrition Rehabilitation techniques Pain relief

Safe use of medications Self-care Safe use of devices and equipment

Mental health and social well being

Financing costs of care

How to get reliable health information

Two Goals: Safe and efficient discharge, and continuing care in the community The Attending Physician leads the health care team in discharge planning. Information, understanding and therapeutic alliance are essential components of discharge planning

Discharge planning begins upon admission and continues throughout confinement. Discharge planning for chronic care patients anticipates many health care needs and helps patients gain access to community health care resources.

Team Communication

Coordinating Care
Universal Protocol Family Meeting Discharge Planning

August 23, 2011

Your patient has an unclear history of allergies and needs a stat CT scan with contrast. How will you deal with this problem? (More than one answer)
A. You will clearly write the indication and precautions

on the chart B. You will ask your RIC to just accompany your patient to CT scan. C. You will use SBAR to communicate your concerns to the patient and NIC. D. You will use SBAR in conferring with the radiologist on the choice of imaging procedure and precautions

Your patient has an unclear history of allergies and needs a stat CT scan with contrast. How will you deal with this problem? (More than one answer)
A. You will clearly write the indication and precautions

on the chart B. You will ask your RIC to just accompany your patient to CT scan. C. You will use SBAR to communicate your concerns to the patient and NIC. D. You will use SBAR in conferring with the radiologist on the choice of imaging procedure and precautions

Your patient has an unclear history of allergies and needs a stat CT scan with contrast. How will you deal with this problem? (More than one answer)
A. You will clearly write the indication and precautions

on the chart B. You will ask your RIC to just accompany your patient to CT scan. C. You will use SBAR to communicate your concerns to the patient and NIC. D. You will use SBAR in conferring with the radiologist on the choice of imaging procedure and precautions

Your patient has an unclear history of allergies and needs a stat CT scan with contrast. How will you deal with this problem? (More than one answer)
A. You will clearly write the indication and precautions

on the chart B. You will ask your RIC to just accompany your patient to CT scan. C. You will use SBAR to communicate your concerns to the patient and NIC. D. You will use SBAR in conferring with the radiologist on the choice of imaging procedure and precautions

You admit a 78/F for dizziness and heart failure. She has cataracts and insomnia. How will you help prevent accidental falls?
A. You will review the falls risk assessment of the nurse

on the Patient Assessment Form and the falls prevention protocol for her. B. You will go over the falls prevention protocol with the Nurse in Charge. C. You will go over the falls prevention protocol with the patient. D. You will communicate your concerns with the Nurse in Charge and the patient using SBAR.

You admit a 78/F for dizziness and heart failure. She has cataracts and insomnia. How will you help prevent accidental falls?
A. You will review the falls risk assessment of the nurse

on the Patient Assessment Form and the falls prevention protocol for her. B. You will go over the falls prevention protocol with the Nurse in Charge. C. You will go over the falls prevention protocol with the patient. D. You will communicate your concerns with the Nurse in Charge and the patient using SBAR.

You order ceftazidime IV on the patients chart and give the chart back to the nurse. What do you do next?
A. You tell the nurse to note the antibiotic order

before leaving the station. B. You ask the nurse to read back the order to you and then you confirm it. C. You tell the nurse to just contact the RIC if she has any questions. D. You ask the nurse if she can read your order.

The following statements are true regarding the sign in briefing procedure:
A. B. C. D. E.

Surgeon must brief the team about the key points of the surgery, potential problems and risks The sign in procedure must be done before anesthesia induction Anesthesiologist must brief the team about airway route and any difficulties A and C only All of the above

When may a sign out debriefing be conducted?

A.
B. C. D. E.

While wound is being closed, surgeon review the key intra-operative events and post-operative care plan while the wound is being closed Before drapes are removed, anesthesiologist review key intra-operative events and post-anesthesia recovery plan While sutures are being placed, nurses confirm sponge and instrument counts A and C only All of the above You will clearly write the indication and precautions on the chart

Attending physicians can plan for discharge during admission by

A. Activating the relevant pathway B. Reconciling medications before and after

admission C. Informing the patient of the expected LOS D. All of the above

Planning for discharge must begin:

A. On the day of discharge B. 24 hours before discharge

C. 48 hours before discharge

D. On the day of admission

The components of discharge planning include the following EXCEPT

A. Providing evidence-based information to the

patient B. Ensuring the patients understanding C. Establishing rapport and trust with patient and family D. Reaffirming therapeutic alliance with the patient